Prep U NCLEX Review

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? a. P wave b. PR interval c. QRS Complex d. T wave

P wave The P wave depicts atrial depolarization or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.

A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which should be the primary focus of nursing care for this client? a. Provide activities of daily living on the time schedule of the client's homeland. b.Offer foods that the client enjoys in order to increase the intake of calories. c. Decrease cardiac demands by promoting rest. d. Listen to concerns about the hospitalization.

c. Decrease cardiac demands by promoting rest This client has clinical manifestations of thalassemia major, a disease found in descendants from the Mediterranean Sea area whose mother and father both possess a gene for thalassemia (i.e., the client is homozygous for the gene). The severe hemolytic anemia causes sequestration of red blood cells in the spleen and liver, which leads to engorgement of the organs and chronic bone marrow hyperplasia. Rest will decrease the demands on the heart due to the diminished hemoglobin level, a physiologic concern.

The nurse is notified that a neonate who was discharged several days ago has a phenylketonuria (PKU) metabolic screening test result of 7 mg/dL. What action should the nurse take? a. Notify the parents to bring the neonate to the hospital to repeat the test. b. Notify the healthcare provider of the normal test result. c. Notify the blood bank because the neonate requires a blood transfusion. d. Notify the healthcare provider because the test result is critically elevated.

b. notify the healthcare provider of the normal test result A normal test result for PKU metabolic screening is < 2 mg/dL; a level of 7 mg/dL is critically elevated. The nurse should immediately notify the healthcare provider who should then notify the parents and ask them to bring the neonate to the facility for immediate evaluation.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital? a. sit up straight in a chair to develop the back muscles, as this will help the client walk with crutches. b. keep the affected limb in extension and abduction at all times. c. conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. d. while walking, do weight bearing on the cast to increase balance

c. conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking.

The nurse is evaluating the test results of a client undergoing testing for depression. Which results of from a dexamethasone suppression test (DST) would the nurse interpret as indicative of depression? a. decreased serum protein b. elevated afternoon serum cortisol c. elevated morning serum amitriptyline d. decreased serum creatinine

b. Elevated afternoon serum cortisol The nurse would interpret an elevated serum cortisol level in the afternoon as indicative of depression in the client undergoing a DST test. DST is a blood test that determines the serum cortisol level after administration of dexamethasone, an agent that usually suppresses the serum cortisol level. The DST has gained considerable attention in the mental health field as a diagnostic marker for endogenous depression as well as for its implications for the treatment and prognosis of this disorder. Most studies have found that 40-50% of clients with endogenous depression or major depression with melancholia do not have a suppressed late-afternoon serum cortisol level after dexamethasone administration.

A nurse is caring for a toddler diagnosed with an inoperable brain tumor. The parents are having difficulty deciding on a treatment plan. What is the nurse's primary role during treatment plan meetings? a. help parents understand the child's prognosis and the treatment options b. act as a liaison among the child, the parents, and the healthcare team c. recommend community resources that can support the client and parents d. provide emotional support to the parents during the decision-making process

b. act as a liason among the child, the parents and the healthcare team It is important to involve the nurse to act as a liaison among all parties. The nurse has the most direct contact with the child and parents, and the nurse can listen to and communicate their wishes for treatment. The nurse can also aid in interpreting information about the child's condition and course of treatment, helping the parents to make an informed decision. The nurse does have knowledge of community resources to support the parents, but that is not the reason for the nurse to be included in the decision making.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? a. respiratory rate of 16 breaths/minute b. oxygen saturation of 93% c. runs of ventricular tachycardia d. blood pressure increase from 120/74 mm Hg to 134/80 mm Hg

c. runs of ventricular tach Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine, 5 mcg/kg/minute I.V. Which classification best describes dobutamine? a. Indirect-acting dual-active agent b. Direct-acting beta-active agent c. Indirect-acting beta-active agent d. Direct-acting alpha-active agent

B. Direct acting beta active agent Adrenergic agents are classified according to their method of action and the type of receptor on which they act. Direct-acting agents act on the sympathetically innervated organ or tissue, whereas indirect-acting agents trigger the release of a neurotransmitter, usually norepinephrine. Dual-acting agents combine direct and indirect actions. Adrenergic agents act on alpha, beta, and dopamine receptors. Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent.

The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal birth. What should the nurse should do next:? a. Apply an ice pack to the perineal area. b. Assess the client's temperature. c. Have the client take a warm sitz bath. d. Contact the health care provider (HCP) for orders for an antibiotic.

a. Apply an ice pack to perineal area The client has a hematoma. During the first 24 hours postpartum, ice packs can be applied to the perineal area to reduce swelling and discomfort. Ice packs usually are not effective after the first 24 hours.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? a. pulmonary hypertension b. chronic obstructive pulmonary disease (COPD) c. empyema d. pulmonary tuberculosis

a. Pulmonary hypertension Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant's toes are swollen and cool to the touch. What should the nurse instruct the mother to do? a.Place the child's legs in a lowered position. b. Have the child fitted for a larger cast. c. Put more cotton wadding to line the casting. d. Inspect the area for an infection

b. Have the child fitted for a larger cast Infants grow rapidly and may require application of a larger cast. A cast adequate for an infant after surgery may be outgrown in less than 1 month. The cast becomes too tight, impairing circulation evidenced by toe swelling and coolness to touch.

A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an IV of D5 NS + 20 mEq KCl/L running at 60 mL/h. The vital signs are temperature 100.4°F (38°C), heart rate 120 bpm, respiratory rate 28 breaths/min, and oxygen saturation 92%. Using the SBAR (situation-background-assessment-recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which medication? a. rectal diazepam. b. IV lorazepam. c. rectal acetaminophen. d. IV fosphenytoin.

b. IV lorazepam V lorazepam is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines act to potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter; stopping seizure activity. If an IV is not available, rectal diazepam is the benzodiazepine of choice. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin is given.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next? a. Hold the feeding and recheck the residual in 4 hours. b. Return the residual and begin the feeding. c. Administer an amount of water equivalent to the feeding. d. Discard the residual and subtract the residual amount from the feeding.

b. Return the residual and begin the feeding The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client.

During dialysis, the client has disequilibrium syndrome. What should the nurse do first? a. Administer oxygen per nasal cannula. b. Slow the rate of dialysis. c. Reassure the client that the symptoms are normal. d. Place the client in modified Trendelenburg's position.

b. Slow the rate of dialysis If disequilibrium syndrome occurs during dialysis, the most appropriate intervention is to slow the rate of dialysis. The syndrome is believed to result from too-rapid removal of urea and excess electrolytes from the blood; this causes transient cerebral edema, which produces the symptoms. Administration of oxygen and position changes do not affect the symptoms.

A client expresses experiencing stress when working but enjoys the challenges this work presents. What would the nurse suggest? a. Find ways to make work fun. b.Take stress-management classes. c. Spend more time with the family. d. Leave work at work.

b. Take stress management classes The nurse would suggest stress-management classes, which would identify factors that contribute to stress in the client's life and teach how to manage stress more effectively. The client may not be able to make the job fun. The information provided by the client does not indicate that spending too little time with the family and taking the job home contribute to the client's stress.

The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant? a. Suggesting to the infant's caregiver to continue to try to feed the infant even when the infant is crying. b. Weighing the unclothed infant at the same time every day. c. Reporting the caregiver to social services for suspected abuse. d. Requiring the caregiver to attend a community support group prior to discharge.

b. Weighing the unclothed infant at the same time every day Daily weights are an appropriate intervention for an infant with failure to thrive.

A "read-back" procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. When should this procedure be implemented? a. When the float nurse gives a written report to the oncoming nurse b. When the nurse receives a critical lab value via phone or in-person from the lab c. When the lab report shows up on the computerized medical record d. When the unit clerk takes a telephone prescription for a stat lab test

b. When the nurse receives a critical lab value via phone or in person from the lab For any verbal or telephone prescription or result, it is important to read back the information to assure its accuracy. It is also important to document that it was read back according to facility policy.

A client with atrial fibrillation has been receiving warfarin. The INR is 4.5. What is the next action the nurse should take? a. Assess the next bowel movement for melena. b. Withhold the next scheduled dose. c. Administer vitamin K. d. Provide an extra serving of green vegetables.

b. Withhold the next scheduled dose Warfarin is an anticoagulant that prolongs the ability of blood to clot by inhibiting vitamin K. The international normalized ratio (INR) is a calculation that standardizes the prothrombin time (PT) to evaluate the effects of oral anticoagulant therapy. The normal range for INR is generally between 1 and 2. Therapeutic ranges are between 2 and 3 for most clients, and from 2.5 to 3.5 for clients with mechanical heart valves. Since this client's value is above the parameters for safe administration, the nurse should withhold the medication until the prescriber has been notified.

Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first? a. a client at 13 weeks' gestation who is experiencing nausea and vomiting three times a day with + 1 ketones in her urine b. a client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day c. a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain d. a primigravida at 17 weeks' gestation who reports not feeling fetal movement at this point in her pregnancy

c. A client at 32 weeks gestation with preeclampsia and proteinuria +3 who is returning for evaluation of epigastric pain A preeclamptic client with +3 proteinuria and epigastric pain is at risk for seizing, which would jeopardize the mother and the fetus. Thus, this client would be the highest priority

Which category of medications would the nurse expect to administer for a client with myasthenia gravis? a. cholinergic medications, muscle relaxants, and nervous system antagonists b. anticholinergic medications, muscle stimulants, and nervous system stimulants c. cholinesterase inhibitors and corticosteroids d. cholinergic inhibitors, immunosuppressants, and antibodies

c. cholinesterase inhibitors and corticosteroids Cholinesterase inhibitors and corticosteroids will be initiated. Specifically, it is the cholinesterase inhibitors, or anticholinesterase, that provide relief of symptoms by increasing the concentration of available acetylcholine at the neuromuscular junction.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? a. flat b. turned onto the operative side c. elevated no more than 10 degrees d. elevated 30 degrees

d. Elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery.

What adverse reaction might the nurse observe after administering enteric-coated erythromycin to a client? a. weight gain b. constipation c. increased appetite d. nausea and vomiting

d. nausea and vomiting Erythromycin is an antibiotic. Common adverse effects include nausea, vomiting, diarrhea, abdominal pain, and anorexia. It should be given with a full glass of water and after meals, or with food, to lessen gastrointestinal symptoms.

The nurse is caring for a client with a developmental disability who needs additional education regarding management of type 2 diabetes. What should the nurse assess to determine the amount and level of education to provide to the client? a. chronologic age b. developmental stage c. functional age d. behavioral disability

b. developmental age The nurse should assess the client's developmental stage to determine the amount and level of educational information to provide to the client as this can impact the client's ability and readiness to learn.

.The emergency department nurse is assessing a client with reports of right-sided dull, abdominal and flank pain, nausea, and vomiting. The client's temperature is 101.2° F (38.4° C), pain is 10 out of 10, and rebound tenderness is exhibited. The health care provider orders: VS q 30 min, CBC, morphine 2 mg IM q 4 hours, regular diet, and enemas until clear. Which orders should the nurse question? Select all that apply a. vital signs b. enemas until clear c. CBC d. morphine e. regular diet

b. enemas until clear e. regular diet The nurse should question the enema order, as enema could cause the appendix to burst. If the condition is appendicitis, the client should be NPO for possible surgery so a regular diet should not be given to the client.

The school nurse is assessing a client for "pinkeye." Which findings would cause the nurse to send the client home? a. wet eyelids with no evidence of swelling b. purulent discharge noted from the eyes c. conjunctiva pink without swelling d. serous drainage from the conjunctiva

b. purulent discharge noted from the eyes A client with purulent discharge from the eyes has bacterial infectious conjunctivitis. Bacterial infectious conjunctivitis will need antibiotic treatment and the client will need to be sent home. Wet eyelids and pink conjunctiva without swelling are normal findings. Serous drainage is associated with viral infectious conjunctivitis.

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? a.Place an indwelling catheter. b. Monitor fetal heart tones. c. Perform a cervical examination. d. Prepare the client for cesarean birth.

b. Monitor fetal heart tones Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the mother or fetus.

A client has been diagnosed with bacterial pneumonia. After 1 day of IV antibiotic therapy, the client's white blood cell count is still 14,000/mm3 (14 X 109/L). The nurse should: a. notify the health care provider. b. recheck the client's white blood cell count in 24 hours. c. initiate reverse isolation precautions. d. administer the next scheduled antibiotic dose early.

a. notify the HCP If the white blood cell count does not begin decreasing, it may indicate that the antibiotic is not effective against the organism causing the pneumonia. The health care provider should be notified as he or she may want to consider changing antibiotics.

A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents? a. ask the community health nurse to visit the family b. provide written care instructions for the parents c. help the parents schedule a f/u w/ pediatrician before dc d. arrange a meeting between HCP and parents to develop care of pla

d. Arrange a meeting between the health care team and the parents to develop a care plan. A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed to prepare the parents for discharge. Written instruction should supplement teaching, not replace it.

A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate? a. "Insert the diaphragm 4 hours before intercourse." b. "Leave the diaphragm in place for at least 6 hours after intercourse." c. "Remove the diaphragm immediately after intercourse." d. "You may use the diaphragm without spermicidal jelly or cream."

b. Leave the diaphragm in place for at least 6 hours after intercourse The diaphragm acts as a reservoir for spermicidal jelly or cream and must be left in place for at least 6 hours after intercourse to ensure spermicidal action. Inserting the diaphragm 4 hours before intercourse or removing it immediately afterward doesn't ensure spermicidal effectiveness.

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the health care provider immediately? a. mouth breathing b. foul odor from the mouth c. moderate intercostal retractions d. irregular respirations while awake

c. Moderate intercostal retractions Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician. Mouth breathing and a foul odor from the mouth aren't cause for concern. Irregular respirations while awake are not an unusual finding in a young child.

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. What should the nurse do next? a. Notify the health care provider (HCP). b. Tell the client that this is normal because intracranial pressure (ICP) fluctuates throughout the day. c. Instruct the client to increase fluid intake prior to going to bed to prevent headache in the morning. d. Advise the client to request pain medication from the health care provider (HCP).

a. Notify the health care provider ICP is highest in the early morning, and the client with hydrocephalus may be experiencing signs of increased ICP that need to be treated. The increased ICP is not related to fluid levels, and the nurse should not advise the client to increase fluid intake. While ICP does fluctuate during the day, it is highest in the morning, and the nurse should notify the HCP .

The nurse is caring for a client in active labor and notes minimal variability on the external fetal monitor tracing. What are the nurse's priority interventions? a. Position to left lateral, O2 per nonrebreather mask at 10 L. b. Position to knee-chest, increase IV fluids. c. Give orange juice, vibroacoustic stimulation. d. Administer terbutaline, turn off oxytocin infusion.

a. Position to left lateral, O2 per nonrebreather mask at 10L. Position to left lateral and administering O2 per nonrebreather mask at 10 L will improve fetal hypoxia and increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. Positioning to knee-chest will improve circulation and oxygenation, but it is easier and faster to move to left lateral. Increasing IV fluids will support maternal circulation and is recommended, but would not be the priority in this instance. Giving orange juice and using vibroacoustic stimulation are used to "wake a baby up" from a sleep state for a nonstress test (NST) and will not improve oxygenation. Administering terbutaline and turning off oxytocin infusion will improve uterine perfusion, but would not be the priority action for decreased variability.

A nurse is assigned four clients. Which client should the nurse see first? a. A 17-year-old client 24 hours post appendectomy b. A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome c. A 50-year-old client three days post myocardial infarction d. A 50-year-old client with diverticulitis

b. A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome Guillain-Barré syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation seen first.

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. What is most important for the nurse to ask the family about the baby's symptoms? a. "Does water ever get into the baby's ears during shampooing?" b. "Do you give the baby a bottle to take to bed?" c. "Have you noticed a lot of wax in the baby's ears?" d. "Can the baby combine two words when speaking?"

b. Do you give the baby a bottle to take to bed? In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media.

After one week in the hospital for chemotherapy treatment related to lymphocytic leukemia, a client develops abdominal pain, fever, and foul-smelling diarrhea. What priority recommendation does the nurse make to the healthcare provider? a. Prescribe an antidiarrheal medication. b. Collect a sample for stool culture and sensitivity. c. Collect stool sample for Clostridium difficile. d. Prescribe STAT intravenous fluid therapy.

c. Collect a stool sample for C. Difficile Immunosuppressed clients — for example, clients receiving chemotherapy — are at risk for infection with C. difficile, which causes foul-smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. A stool culture and sensitivity does not test specifically for C. diff and is not recommended for clients who have been hospitalized for more than 3 days.

Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? a. Encourage activity as tolerated. b. Provide a high-protein, fluid-monitored diet. c. Monitor patient blood pressure. d. Place the client on a sheepskin, and monitor for increasing edema.

c. Monitor patient blood pressure Blood pressure control is a priority assessment in clients with poststreptococcal glomerulonephritis. The blood pressure can be increased for up to 6 weeks after treatment

While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, what should the nurse do next? a.Push the "code blue" (emergency response) button. b. Call the rapid response team. c. Open the client's airway. d. Call for a defibrillator.

c. Open the clients airway The nurse has already called for help and established unresponsiveness so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required.

A 17-year-old unmarried primigravida client at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do first? a. Instruct the client in methods for low-cost, highly nutritious meal preparation. b. Determine whether the client qualifies for local assistance programs. c. Refer the client to a social worker for enrollment in a food assistance program. d. Ask the client if she has a job and the amount of income earned

c. Refer the client to a social worker for enrollment in food assistance programs

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy? a. decrease in appetite b. drowsiness c. spasms of the diaphragm d. cough and shortness of breath

c. cough and shortness of breath Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.

A child with Wilms' tumor has had a kidney removed, and is now receiving chemotherapy. What priority information should the nurse share with this child's family at the time of discharge? a. Avoid contact sports. b. Limit fluid intake as ordered. c. Decrease sodium intake. d. Avoid contact with other children.

d. avoid contact sports Because the child has only one kidney, certain precautions are recommended to prevent injury to the remaining kidney. Fluid intake is essential for renal function, and should not be decreased. The child's sodium intake shouldn't be reduced. Avoiding other children is unnecessary, may make the child feel self-conscious, and may lead to regressive behavior.

When caring for a client with quadriplegia, which nursing intervention is the priority? a. Forcing fluids to prevent renal calculi b. Maintaining skin integrity c. Obtaining adaptive devices for more independence d. Preventing atelectasis

d. preventing atelectasis Clients with quadriplegia have paralysis or weakness of the diaphragm, abdominal, or intercostal muscles. Maintenance of airway and breathing take top priority. Although forcing fluids, maintaining skin integrity, and obtaining adaptive devices for more independence are all important interventions, preventing atelectasis is the priority.

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which health care provider order? a. "Monitor urine output every hour." b. "Infuse IV fluids at 83 ml/hour." c. "Administer oxygen by nasal cannula at 3 L/minute." d. "Draw samples for hemoglobin and hematocrit every 6 hours."

b. Infuse IV fluids at 83ml/ hour Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid IV fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An IV infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem.

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation? a. yellow, waxy deposits on the lower eyelids b. bright red moles on the hands c. several areas of dry, scaly skin d. small, waxy nodule with pearly borders

b. bright red moles on the hands A small waxy nodule with pearly borders may indicate a basal cell carcinoma. This finding requires further investigation and treatment. Yellow, waxy deposits on the lower eyelids, bright red moles on the hands, and areas of dry, scaly skin are normal age-related changes to skin.

An infant is to have moderate sedation for an outpatient procedure. The nurse knows that: a. the infant should respond to gentle tactile or verbal stimulation. b. the infant's reflexes will be decreased or absent. c. the infant will remember the procedure. d. the infant will need a patient-controlled analgesia (PCA) pump during sedation.

a. The infant should respond to gentile tactile or verbal stimulation an infant under moderate sedation should respond to verbal or tactile stimuli. Infants under general anesthesia have decreased or absent reflexes. Infants who undergo general or moderate sedation rarely remember the procedure. PCA pumps aren't used during sedation.

The nurse should teach the diabetic client that which is most indicative of hypoglycemia? a. nervousness b. anorexia c. Kussmaul respirations d. bradycardia

a. nervousness The four most commonly reported signs and symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Other signs and symptoms include hunger, incoherent speech, tachycardia, and blurred vision. Anorexia and Kussmaul respirations are clinical manifestations of hyperglycemia or ketoacidosis.

A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. respiratory stress

c. Metabolic acidosis The client's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and coma. These symptoms, along with cardiovascular collapse and shock, require aggressive and intensive therapy if the client is to survive.

A nurse is assessing an adult who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm3 (22 × 109/L) and has petechiae on the lower extremities. What should the nurse should instruct the client to do? a. Increase the amount of iron in the client's diet. b. Apply lotion to the lower extremities. c. Elevate the legs. d. Consult the health care provider.

d. consult the health care provider Petechiae are tiny, purplish, hemorrhagic spots visible under the skin. Petechiae usually appear when platelets are depleted. Bleeding gums or oozing of blood may accompany the petechiae, and the client should seek medical assistance immediately.

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy? a. decrease in appetite b. drowsiness c. spasms of the diaphragm d. cough and shortness of breath

d. cough and shortness of breath Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.

A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the area on vacation. The client states that the nurse must be having a busy shift and asks about the maximum number of clients that the nurse is allowed to care for. What is the nurse's best response? a. "Some jurisdictions have staffing laws that allow for nurses to be involved in staffing ratios." b. "Staffing laws are standardized across all jurisdictions." c. "When was the last time you were involved in your staffing committee?" d. "This facility does not need to disclose to the public about our staffing pattern and ratios."

a. "Some jurisdictions have staffing laws that allow for nurses to be involved in staffing ratios." Staffing laws exist in some jurisdiction, but not others. Staffing laws tend to fall into one of three general approaches: The first is to require hospitals to have a nurse-driven staffing committee that creates staffing plans that reflect the needs of the patient population and matches the skills and experience of the staff. The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation. A third approach is requiring facilities to disclose staffing levels to the public and/or a regulatory body. A facility is required to disclose staffing levels to the public.

The nurse is preparing the prescribed medications for a client. Which medication will the nurse prioritize obtaining a witness for wasting a partial dose? a. lorazepam 1 mg PO; dose available 2 mg tablet b. hydromorphone 2 mg I.V.; dose available 2 mg/ml vial c. pregabalin 50 mg PO; dose available 100 mg tablet d. amiodarone 150 mg I.V.; dose available 300 mg/10 ml vial

a. Lorazepam 1mg PO; dose available 2mg/ml vial Federal law requires two nurses to witness and document the waste of any partial dose of a controlled substance. Lorazepam is a controlled substance, therefore the waste of 1 mg, or 1/2 of the 2 mg tablet, will require another nurse as witness. Hydromorphone is a controlled substance, but the prescription requires the full dose to be administered